Print Violation: 00374485-AP-324837

Provider Information

Mt. Bachelor Memory Care

20225 POWERS ROAD
Bend, OR 97702

Date: 12/18/2024
Report number: 00374485-AP-324837
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0055(1)(a)(f) and (2)
Findings: The Alleged Victim (AV) has severe cognitive deficits and relies on the facility to administer his/her medications. According to an investigation, on or about December 18, 2024, the Alleged Perpetrator 2 (AP2) marked AV had been "given" their thyroid medication on AV's electronic record when AP2 had not administered the medication. This exposed AV to potential risk of serious harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.